Long-term prevention of skeletal complications of metastatic breast cancer with pamidronate. Protocol 19 Aredia Breast Cancer Study Group

PURPOSE

Pamidronate, an aminobisphosphonate, has been shown to lower the risk of skeletal complications associated with lytic bone lesions for up to 1 year in women with stage IV breast cancer who received chemotherapy. We studied the long-term effectiveness and safety of continued treatment with intravenous pamidronate infusions for up to 2 years.

PATIENTS AND METHODS

Three hundred eighty-two women with metastatic breast cancer and lytic bone lesions who received chemotherapy were randomly assigned to receive either 90 mg of pamidronate or placebo intravenously every 3 to 4 weeks in this double-blind, multicenter, parallel-group trial. Patients were evaluated monthly for 2 years for skeletal complications, which included pathologic fractures, need for radiation or surgery to treat bone complications, spinal cord compression, and hypercalcemia. Bone pain, analgesic use, bone biochemical markers, performance status, quality of life, radiologic response in bone, and survival were also evaluated.

RESULTS

As in the first year of treatment, the proportion of patients with any skeletal complication was significantly less for the pamidronate than the placebo group at 15, 18, 21, and 24 months (P < .001). The proportions of patients with any pathologic fracture (i.e., vertebral and nonvertebral fractures), need for radiation or surgery to treat bone complications, and hypercalcemia were also statistically less for the pamidronate than the placebo group. The median time to the first skeletal complication was 13.9 months in the pamidronate-treated women and 7.0 months in the placebo group (P < .001). Long-term treatment did not result in any unexpected adverse events. Survival did not differ between the two groups.

CONCLUSION

The risk for osteolytic bone lesion complications in metastatic breast cancer was significantly decreased with monthly infusions of 90 mg of pamidronate, and this effect was maintained for at least 2 years. Pamidronate is a useful adjunct to standard chemotherapy in the palliative treatment of metastatic breast cancer.

Long-term pamidronate treatment of advanced multiple myeloma patients reduces skeletal events. Myeloma Aredia Study Group

PURPOSE

To determine the efficacy and safety of 21 monthly cycles of pamidronate therapy in patients with advanced multiple myeloma.

PATIENTS AND METHODS

Patients with stage III myeloma and at least one lytic lesion received either placebo or pamidronate 90 mg intravenously administered as a 4-hour infusion monthly for 21 cycles. At study entry, the patients were stratified according to whether they were to receive first-line (stratum 1) or second-line (stratum 2) antimyeloma chemotherapy. Skeletal events (pathologic fracture, radiation or surgery to bone, and spinal cord compression) and hypercalcemia were assessed monthly.

RESULTS

The results of the first nine previously reported cycles are extended to 21 cycles. Of the 392 randomized patients, efficacy could be evaluated in 198 who received pamidronate and 179 who received placebo. After 21 cycles, the proportion of patients who developed any skeletal event was lower in the pamidronate-group (P = .015). The mean number of skeletal events per year was less in the pamidronate-group (1.3) than in placebo-treated patients (2.2; P = .008). Although survival was not different between the pamidronate-treated group and placebo patients overall, stratum 2 patients who received pamidronate lived longer than those who received placebo (14 v 21 months, P = .041). Pamidronate was safe and well tolerated during the 21 cycles of therapy.

CONCLUSION

Long-term monthly infusions of pamidronate as an adjunct to chemotherapy are superior to chemotherapy alone in reducing skeletal events in stage III multiple myeloma patients, and may improve the survival of patients on salvage therapy.

Imaging of fallopian tube tumors

OBJECTIVE

The purposes of this study were to investigate the imaging findings in patients with primary fallopian tube neoplasms and to determine whether specific imaging features favor the preoperative diagnosis of fallopian tube tumors (FTT).

MATERIALS AND METHODS

Computerized search of medical records from 1984 to 1994 identified 20 patients with a discharge diagnosis of primary fallopian tube carcinoma. Medical records, imaging studies, and pathology findings were reviewed. Eleven patients had available preoperative imaging.

RESULTS

Seventeen of 20 patients with primary FTT had unilateral disease. Of these 17, preoperative imaging was available in nine, showing four solid adnexal masses, four complex cystic adnexal masses, and one normal adnexa. The preoperative imaging of these nine patients included six sonographic and five CT studies. Three patients with primary FTT had bilateral tumors, and preoperative imaging was available for two patients: Two sonographic studies and one CT study showed one complex cystic adnexal mass and three normal adnexa.

CONCLUSION

Primary FTT commonly presents as an adnexal mass on preoperative imaging and mimics other pelvic malignancies, especially ovarian carcinoma. Making a specific preoperative diagnosis is difficult; however, because primary FTT is unlikely to be confused with a benign process, delay in diagnosis is rare.

Efficacy of pamidronate in reducing skeletal complications in patients with breast cancer and lytic bone metastases. Protocol 19 Aredia Breast Cancer Study Group

BACKGROUND

Bisphosphonates such as pamidronate disodium inhibit osteoclast-induced bone resorption associated with cancer that has metastasized to bone.

METHODS

Women with stage IV breast cancer who were receiving cytotoxic chemotherapy and had at least one lytic bone lesion were given either placebo or pamidronate (90 mg) as a two-hour intravenous infusion monthly for 12 cycles. Skeletal complications, including pathologic fractures, the need for radiation to bone or bone surgery, spinal cord compression, and hypercalcemia (a serum calcium concentration above 12 mg per deciliter [3.0 mmol per liter] or elevated to any degree and requiring treatment), were assessed monthly. Bone pain, use of analgesic drugs, performance status, and quality of life were assessed throughout the trial.

RESULTS

The efficacy of treatment was evaluated in 380 of 382 randomized patients, 185 receiving pamidronate and 195 receiving placebo. The median time to the occurrence of the first skeletal complication was greater in the pamidronate group than in the placebo group (13.1 vs. 7.0 months, P=0.005), and the proportion of patients in whom any skeletal complication occurred was lower (43 percent vs. 56 percent, P = 0.008). There was significantly less increase in bone pain (P=0.046) and deterioration of performance status (P=0.027) in the pamidronate group than in the placebo group. Pamidronate was well tolerated.

CONCLUSIONS

Monthly infusions of pamidronate as a supplement to chemotherapy can protect against skeletal complications in women with stage IV breast cancer who have osteolytic bone metastases.

Endometrial polyps, hyperplasia, and carcinoma in postmenopausal women: differentiation with endovaginal sonography

PURPOSE

To characterize endometrial polyps, hyperplasia, and carcinoma with endovaginal ultrasound in postmenopausal women.

MATERIALS AND METHODS

Seventy-three postmenopausal women with abnormally thick endometria on endovaginal sonograms were retrospectively identified. The endometrial appearance was characterized as hyperechoic, containing cystic spaces, or heterogeneous. The final study group consisted of 68 women, in whom the pathologic and sonographic findings were correlated.

RESULTS

Thirty sonograms showed hyperechoic endometria in women with hyperplasia (n = 8), polyps (n = 4), polyps and hyperplasia (n = 2), or atrophy, proliferative change, mild atypia, or normal endometria (n = 16); 27 sonograms showed cystic spaces in women with polyps (n = 21), carcinoma (n = 1), polyps and hyperplasia (n = 2), or atrophy (n = 3); and 11 sonograms showed heterogeneous endometria in women with endometrial carcinoma (n = 7), atrophy (n = 2), proliferative endometrium (n = 1), or secretory endometrium (n = 1). Cystic spaces were predictive of polyps (P = 1.19 x 10(-10)).

CONCLUSION

Endovaginal sonography may be useful for differentiation of endometrial polyps, hyperplasia, and carcinoma.

Efficacy of sonographically guided biopsy of thyroid masses and cervical lymph nodes

OBJECTIVE

We performed a prospective study in 96 patients to determine accuracy of sonographically guided fine-needle aspiration biopsy of thyroid masses and cervical lymph nodes.

MATERIALS AND METHODS

Real-time sonography was used to guide biopsy of 112 cervical masses in 96 patients (71 patients with impalpable masses, 16 with failed unguided attempts, patient's or physician's preference in nine). The diameters of all masses were less than 3 cm, with a mean of 1.5 cm and a median of 1.5 cm. Twenty-nine masses measured 1 cm or less in diameter, 60 masses between 1.1 and 2.0 cm, and 23 masses between 2.1 and 3.0 cm. Cervical masses that were sampled by biopsy included 75 thyroid masses and 37 lymph nodes.

RESULTS

Diagnostic specimens were obtained in 102 (91%) of 112 masses sampled. Sixty-eight (91%) of 75 biopsies of thyroid tissue and 34 (92%) of 37 biopsies of lymph nodes were diagnostic. Nondiagnostic thyroid biopsies included four of complex cysts and three of solid nodules. Sonographic follow-up (1 year) revealed no change or decrease in size of those seven lesions. Sixty of 68 diagnostic thyroid biopsies showed benign processes: 42 macrofollicular adenomas, six colloid adenomas, five microfollicular adenomas, four probable cases of thyroiditis, and three hemorrhagic cysts. The remaining eight diagnostic thyroid biopsies showed malignant processes: seven papillary carcinomas and one metastatic small-cell carcinoma. Of 34 diagnostic biopsies of lymph nodes, 26 showed malignant processes and eight showed benign processes. Surgery in the three patients with nondiagnostic biopsies of lymph nodes revealed two recurrent medullary cancers and one benign node.

CONCLUSION

Sonographically guided fine-needle aspiration biopsy of neck masses has a high sensitivity (91%) and should be routinely used to evaluate indeterminate masses in the neck.

Fine-needle biopsy of cervical lymph nodes in patients with thyroid cancer: a prospective comparison of cytopathologic and tissue marker analysis

Tissue levels of thyroglobulin (Tg) or calcitonin were compared with specimens from neck lymph node biopsy in patients with suspected recurrent differentiated (papillary or follicular) or medullary thyroid cancer. Thirty-six neck lymph node biopsies were performed in 29 patients. Tissue Tg levels were obtained from 31 specimens from patients with differentiated thyroid cancers, and tissue calcitonin levels were obtained from five specimens from patients with medullary cancer. Thirteen nodes were diagnosed as negative for cancer at surgery (n = 3) or follow-up sonography (n = 10). Malignant disease was confirmed at surgery in 23 of the 36 lymph nodes. Cytopathologic examination had a sensitivity of 91% and a specificity of 100%. Tissue Tg levels ranged from 0 to 3.5 ng/mL (mean, 1.5 ng/mL; median, 1.2 ng/mL) in 12 of the 13 benign lymph nodes and from 21 to 247,500 ng/mL (mean, 30,600 ng/mL; median, 2,330 ng/mL) in the 23 malignant nodes. Tissue calcitonin levels were elevated (range, 850-703,125 pg/mL; mean, 184,762 pg/mL; median, 17,538 pg/mL) in four malignant nodes and were normal (3.0 pg/mL) in one benign node. Diagnostic sensitivity of tissue markers was 91%. Specificity was 91%. The combined diagnostic sensitivity and specificity of tissue marker analysis and cytopathologic examination was 100%.

Optimal technique for detection of gallstones at injection cholecystography: in vitro analysis

Injection cholecystography is often employed during invasive gallbladder procedures to determine the number of gallstones that are present. The authors undertook this study to define the optimal radiographic technique for performance of injection cholecystography. Condoms filled with 100 mL of contrast medium at four different iodine concentrations (30%, 15%, 7.5%, and 3.8% [wt/vol]) and containing up to five 4-mm-thick gallstones or a single 10-mm-thick gallstone were radiographed in a 20-cm-deep water bath by using four kilovolt peak settings (70, 80, 90, and 100 kVp). Images were read by three radiologists who were blinded to the radiographic technique. significantly (P less than .05) improved Decreasing iodine concentration significantly (P less than .05) improved detection of 4-mm-thick gallstones at a constant kilovolt peak setting. However, increasing the kilovolt peak setting while using the same concentration of contrast medium had no statistically significant influence on gallstone detectability, although radiologists did indicate a preference for the high-kilovolt peak technique. Results of the authors' experiments showed that for detection of small gallstones at injection cholecystography, use of a low-concentration contrast medium and a high kilovolt peak setting is the recommended radiographic technique.

Treatment of critically ill patients with sepsis of unknown cause: value of percutaneous cholecystostomy

Because of the difficulty in diagnosing acute cholecystitis in critically ill patients with severe intercurrent illness by clinical and imaging methods or percutaneous aspiration of the gallbladder, a trial of percutaneous cholecystostomy was performed in 24 patients in the intensive-care unit with persistent, unexplained sepsis after a complete clinical, laboratory, and radiologic search showed no alternative source of infection. Persistent high fevers, despite antibiotic therapy, were present in all patients, with elevated WBC count in 18 patients, vague abdominal tenderness in 11, and septic shock requiring vasopressors in 15. Sonographically, all patients had distended, spherical gallbladders, six had gallstones, eight had wall thickening, three had pericholecystic fluid, and four had Murphy's sign. All patients were seen by a senior abdominal surgeon, who agreed to a trial of percutaneous cholecystostomy. Fourteen patients (58%) responded to percutaneous cholecystostomy, as evidenced by a decrease in WBC count, defervescence, and the ability to be weaned off vasopressors. Bile cultures were positive in four patients. Ten patients (42%) did not respond to percutaneous cholecystostomy; five eventually died of unrelated causes. A respiratory source of infection was eventually found in three of these 10 patients, with no proved source of infection in the remainder. No complications related to catheter insertion occurred in this group of patients. Bile leaks occurred in two patients when the percutaneous cholecystostomy catheter was removed, but without serious consequence. Our experience suggests that a lower threshold for performing percutaneous cholecystostomy in this difficult clinical subset of patients is worthwhile.

Benign and malignant adrenal masses: CT distinction with attenuation coefficients, size, and observer analysis

In a retrospective study of adrenal masses evaluated with computed tomography (CT), lesion x-ray attenuation was compared with size and radiologists' interpretations in discriminating benign lesions from malignant ones. Unenhanced CT attenuation coefficient and size were analyzed electronically in 55 patients with 66 adrenal masses. There were 38 nonhyperfunctioning adenomas in 33 patients and 28 malignant masses in 22 patients. Primary extraadrenal malignancies were present in 45 of the 55 patients. Three blinded readers characterized the adrenal masses using a seven-point scale of certainty. Results were subjected to receiver operating characteristic (ROC) analysis. The mean CT attenuation coefficient for benign adrenal masses was -2.2 HU +/- 16.0 and was significantly different from the mean for malignant lesions (28.9 HU +/- 10.6). The area under the ROC curve for CT attenuation coefficients (0.91 +/- 0.04) was significantly larger than that for lesion size (0.84 +/- 0.05) or best observer interpretation (0.84 +/- 0.05). A threshold CT attenuation value of 0 HU had a sensitivity-to-specificity ratio of 47%:100% for characterizing benign adrenal masses, whereas a threshold attenuation of 10 HU had a ratio of 79%:96%.

Simulation of gallstone fragments by cavitation bubbles during extracorporeal shock wave lithotripsy: physical basis and in vitro demonstration

During extracorporeal shock wave lithotripsy of gallstones, sonography often shows a swirling pattern of echogenic foci shortly after the application of shock waves. This effect has been thought to represent gallstone fragments in suspension. However, evidence suggests that this finding is in part due to cavitation, a physical phenomenon associated with the formation or movement of gas bubbles in the fluid-filled gallbladder. Condoms filled with degassed water and five human bile specimens were positioned in the focus of an MPL 9000 lithotriptor (Dornier Medical Systems, Munich). A solitary nonradiopaque gallstone was then added to a bile-filled condom, and the sonographic pattern was observed before and after fragmentation. The mean clearance time of the cavitation bubbles was 4 seconds for degassed water and 22 seconds for human bile. Gallstone fragments were distinguished from cavitation bubbles by their prolonged settling time (up to 30 minutes) along the dependent gallbladder wall.

Clinical use of a nonferromagnetic needle for magnetic resonance-guided biopsy

Five patients who had liver lesions detected by magnetic resonance (MR) and/or computed tomography (CT) were biopsied using MR guidance with a specially designed nonferromagnetic needle. The 20-gauge needle was constructed from Type 316 stainless steel in order to maximize needle visibility and minimize needle-tip artifact. In all cases adequate tissue was obtained for diagnosis and no side effects were observed during the biopsy or on clinical follow-up despite the fact that the needle was within the patient in MR for an average of 30 min.

Infected abdominal tumors: percutaneous catheter drainage

Sixteen patients underwent percutaneous catheter drainage of infected primary (n = 9) or metastatic (n = 7) abdominal tumors. Twelve of the patients improved clinically, as evidenced by defervescence and decrease or normalization of leukocytosis. Four patients did not respond to catheter drainage and required surgery. Three of the twelve who improved underwent operations for attempts at surgical cure or debulking of tumor volume despite an initial "good" response to percutaneous drainage. Of the nine patients who did not undergo surgery after percutaneous drainage, four underwent catheter removal after 5 weeks of drainage and had no recurrence of infection, two remained alive with the catheter in place up to 8 months and 1 year after drainage, and two died with the catheter in place. One patient had the catheter removed inadvertently after 3 weeks of drainage and had recurrences that required replacement of the catheter until his death. The major differences between drainage of necrotic tumors and drainage of standard abscesses were the need for surgery in the majority of the cases and the fact that patients needed the catheters for continued palliation until their death.

Routine sonographic techniques fail to quantify gallstone size and number: a retrospective study of 111 surgically proved cases

We analyzed sonographic images retrospectively to determine their value in quantifying gallstone size and number in 111 surgically proved stone-containing gallbladders for which routine preoperative sonograms were available. The number and size of of stones found on pathologic examination were correlated with the results of image analysis. In patients with more than one stone, observable size differences were recorded if the smallest stone diameter was less than 50% of the largest stone diameter. Estimates of gallstone size and number from preoperative sonograms were correct in only 23 (21%) of 111 cases. Stone size and number were overestimated as often as they were underestimated. Stones of a uniform size were recognized correctly in 59 (92%) of 64 cases. Stones of two different sizes were correctly identified in only 14 (30%) of 47 cases; the second, smaller stones were missed in 26 (79%) of 33 cases. These findings indicate poor sonographic characterization of gallbladder contents when imaging studies are performed solely to determine the presence or absence of gallstones.

Extracorporeal shock-wave lithotripsy of gallstones: Boston experience with the Dornier MPL 9000 lithotripter

After the success of shock-wave therapy for fragmentation of renal stones, machines for shock-wave therapy of gallbladder stones were quick to follow. In Munich, gallstones were successfully treated in 174 of 175 patients who were also taking ursodiol to help solubilize the calculous rubble left after treatment. In Boston, of the initial 87 patients accepted, 58 were treated for a single stone (mean diameter 15.7 mm), 16 were treated for 2 stones, and 13 for 3 stones. Although reporting of exact results is not possible before the Food and Drug Administration issues a clearance, it is fair to say that both patients and physicians are generally pleased with the results.

Imaging of pancreatic neoplasms: comparison of MR and CT

Thirty-two patients with pathologically proved pancreatic carcinomas or cystadenomas were evaluated with MR images obtained with T1-weighted spin echo (short TR/short TE), inversion recovery, and T2-weighted spin-echo (long TR/long TE) pulse sequences. CT was used as the reference standard to determine the ability of MR to delineate normal and abnormal pancreatic anatomy and thereby to exclude or detect pancreatic malignancy. Short TR/short TE spin-echo sequences were significantly better (p less than .05) than inversion recovery or T2-weighted spin-echo sequences in resolution of both normal and abnormal anatomy. Resolution of pancreatic anatomy correlated (r = .9) with the image signal-to-noise ratio. In seven (22%) of 32 cases, MR visualized pancreatic tumors better than CT did because it showed a signal intensity difference between the tumor and normal pancreatic tissue. Overall, the slight superiority of MR over CT for tumor visualization tended to occur in larger tumors and was not statistically significant. On T1-weighted images, 63% (20 of 32) of pancreatic tumors studied had lower signal intensities than normal pancreatic tissue, whereas on T2-weighted sequences (TE = 60, 120, and 180 msec) only 41% (13 of 32) of tumors had increased signal intensities. Currently available MR imaging techniques offer no significant advantages over CT for evaluating the pancreas for neoplasia.

The sonographic diagnosis of acute gangrenous cholecystitis: importance of the Murphy sign

The sonographic Murphy sign is defined as the presence of maximal tenderness elicited by direct pressure of the transducer over a sonographically localized gallbladder. The reported prevalence of this sign is more than 95% in patients with acute cholecystitis. In this series of 18 patients with pathologically proved gangrenous cholecystitis, the sonographic Murphy sign was positive in only six (33%). Clinical examination showed a positive Murphy sign in eight patients (44%), diffuse abdominal pain in nine patients (50%), and no pain in one patient (6%). Other sonographic findings included pericholecystic fluid (10), thickening of the gallbladder wall (10), and a dilated gallbladder (five). Our experience suggests that the absence of the Murphy sign increases the possibility of gangrenous cholecystitis in patients with abdominal pain and sonographic findings of cholecystitis.

Physical characteristics of gallstones removed at cholecystectomy: implications for extracorporeal shock-wave lithotripsy

The criteria by which patients are selected for new, nonsurgical forms of gallstone therapy will influence the use of these techniques. We estimated the number of patients with gallbladder stones who are potentially suitable for extracorporeal shock-wave lithotripsy according to the current Food and Drug Administration protocol for the United States trials of the Dornier gallbladder lithotriptor. Exclusion criteria include patients with (1) more than three stones, (2) stones less than 0.5 cm or more than 3.0 cm in diameter, (3) radiopaque stones, and (4) a nonfunctioning gallbladder. The gallbladder contents in 100 consecutive patients undergoing cholecystectomy were analyzed according to the number, size, and calcium content of the stones as determined by specimen radiographs. Because none of these patients underwent preoperative oral cholecystography, an estimated percentage of functioning gallbladders was taken from the literature. Preoperative symptoms were not considered in determining a patient's eligibility for gallbladder lithotripsy. On the basis of these criteria, we estimated that 85% of our surgical patients would have been excluded from extracorporeal shock-wave lithotripsy according to the current Food and Drug Administration protocol for the Dornier gallbladder lithotriptor.

Thoracic empyema: management with image-guided catheter drainage

Forty-three patients with thoracic empyema were treated by means of image-guided catheter drainage. In 40 patients, image-guided catheter drainage was the primary treatment method; in three it was used after conventional, surgical chest tube placement failed. Drainage was performed with ultrasound guidance in 30 patients (69.8%), computed tomography in eight (18.6%), and fluoroscopy in five (11.6%). A combination of guidance modalities was used in six patients. Image-guided catheter drainage alone was successful in 31 of 43 patients (72.1%). In three patients (7%), empyemas were initially drained, but a thoracotomy was ultimately required because of a persistent pleural peel. In eight patients (18.6%), the procedure failed, predominantly due to tube clogging, persistent pneumothorax, or progressive development of a pleural peel. In one patient, drainage was successful but he died 10 days later of complications of renal failure. No major complications were encountered. Treatment of these patients requires a thorough understanding of the pathogenesis of pleural space infection, principles of empyema drainage, techniques of abscess drainage under image guidance, and the use of a pleural drainage system.

Image-guided pleural biopsies: indications, technique, and results in 23 patients

Twenty-six pleural biopsies were performed on 23 patients over a 3-year period. Twenty-three biopsies were performed guided with ultrasound; one, with computed tomography; and two, with fluoroscopy. Indications for an image-guided pleural biopsy were (a) pleural masses or thickening that were either not seen on chest radiographs or seen only on one view and (b) small or loculated pleural effusions of unknown cause with no mass seen. If only pleural fluid was present, reverse bevel needles were used for biopsy (n = 15). If a discrete pleural mass or thickening was seen with cross-sectional imaging, standard (16-20 gauge) biopsy needles were used (n = 11). In the 23 patients, biopsy results were true positive in ten (nine with malignancy, one with tuberculous pleurisy), true negative in ten (confirmed either at subsequent thoracotomy or clinical follow-up), and false negative in three. Complications were few, with a significant pneumothorax occurring in two patients (8.7%). Image-guided biopsy of small pleural lesions and small pleural effusions can be performed by the radiologist who understands the special needles and techniques involved.

Severe acute pancreatitis after percutaneous biopsy of the pancreas

A retrospective review of 184 pancreatic biopsies in 178 patients was performed to assess the prevalence of severe postbiopsy pancreatitis. The size, contour, and pathology of the lesions biopsied; the course of the needle (i.e., through bowel or other viscera); the size of the needle; the number of needle passes made; and the guidance technique used were analyzed. Severe pancreatitis developed in five cases (five patients) 5/184 or 3% of the biopsies), usually within 24-48 hr. Three of the five patients who developed pancreatitis had true-negative biopsies (normal pancreas) proved either at surgery (two) or at clinical follow-up (one). The diagnoses for the two remaining patients were adenocarcinomas. In four of the five patients, the diagnosis of severe pancreatitis was made by inspection at surgery. The fifth case was diagnosed by CT. Three patients who underwent surgery and one patient who had percutaneous drainage recovered from the pancreatitis. The fifth patient died despite surgical intervention. All five patients with pancreatitis had masses 3 cm or smaller as compared with the overall group, in which 71 (39%) of the 184 biopsies performed had masses smaller than 3 cm. Overall, 18% of the biopsies were true negative, compared with the 60% true-negative rate in the pancreatitis group. The bowel was transgressed in 21% of all 178 patients, including three of the five pancreatitis patients. We conclude that although the risk of pancreatitis is exceedingly small in percutaneous needle biopsies, it may occur, and at a higher rate than previously reported.

Complicated pancreatic abscesses: problems in interventional management

Twenty-five patients with grade D or E pancreatitis underwent percutaneous drainage. These patients required multiple computed tomography (CT) examinations, multiple catheter insertions, multiple catheter manipulations, and long-term catheter drainage. Eight of the 25 patients were successfully treated with catheter drainage alone. Sixteen underwent surgical drainage, ten after attempts at percutaneous drainage and six prior to radiologic drainage. Of the ten patients who had initial percutaneous drainage, only four were clinically improved from the drainage procedure alone. Although the fluid component of the abscess was often adequately drained in all ten patients, surgery was required to remove pieces of necrotic debris. Six patients who underwent surgical debridement had residual abscesses in the post-operative period and were all successfully treated with percutaneous drainage. One patient died from unrelated causes. Successful interventional management of patients with pancreatic abscesses requires intensive radiologic intervention and monitoring and may be better served by a combination of radiologic and surgical means.

Cholecystitis: diagnosis by MR imaging

Morphologic features which allow the diagnosis of acute cholecystitis by ultrasound and CT have now been observed by MR. When present, thickening of the gallbladder wall, intramural abscess, pericholecystic fluid, and the presence of gallstones may be more specific than MR characterization of gallbladder bile.

Sonographic guidance in diagnostic and therapeutic interventions in the pleural space

One hundred eighty-seven diagnostic and therapeutic interventional procedures in the pleural space were performed by using sonographic guidance. These consisted of diagnostic aspiration (118), drainage of malignant and nonmalignant effusions (41), empyema drainage (17), pleural sclerotherapy with tetracycline or bleomycin (7), and pleural biopsy (4). Diagnostic aspiration was performed with 20-gauge needles, and therapeutic and empyema drainages were performed by trocar technique with either a 7-French Sacks catheter or a specially designed empyema drainage catheter. Pneumothoraces were seen in 3% of the patients, and most of these were treated by the radiologist with placement of a Heimlich valve. We conclude that the use of sonography allows rapid localization of pleural fluid collections and instant monitoring of drainage of noninfected fluid collections and empyemas.

Transcystic biopsy: a new approach to posterior pelvic lesions

Six patients with masses located posterior to the bladder were biopsied using an anterior transcystic approach. Conventional biopsy needles were introduced through the bladder with both sonographic (five) and CT guidance (one). Clinically important diagnoses of recurrent carcinoma (four) or cytology-negative fluid (two) were made in all patients. One patient had a transient episode of minimal hematuria immediately after the biopsy. Otherwise, there were no complications. Transcystic biopsy appears to be a safe and effective technique for biopsy or aspiration of posterior pelvic masses.

Chronic cholecystitis. An analysis of diagnostic strategies

To define the optimal diagnostic approach for suspected chronic cholecystitis comprehensive management strategies were developed. Using a computer model, the frequency of appropriate surgery, inappropriate surgery, complications, death, and medical costs were compared in populations of patients with various disease prevalences. The optimal strategy began with ultrasonography, followed by an oral cholecystogram when the ultrasonogram was inconclusive. Oral cholecystogram also was employed when additional diagnostic studies failed to provide another explanation for the patient's symptoms. Compared with strategies using only ultrasonography or oral cholecystography, the combination strategy lowered the frequency of inappropriate surgery from 7.1 to 4.4% and direct medical costs from $1,877 to $1,766 per patient in a population with a 20% prevalence of chronic cholecystitis. The differences persisted at higher prevalences of cholecystitis and when sensitivities and specificities of the tests were varied over ranges reported in the literature. Diagnostic accuracy and direct medical costs could be improved by a more frequent interpretation of subtle abnormal ultrasonographic findings as inconclusive and by a more liberal use of oral cholecystography. This analysis demonstrates that a strategy combining ultrasonography and oral cholecystography is superior to the use of either test alone and is cost-efficient.

Sonography in the follow-up of 100 patients with thyroid carcinoma

High-frequency, high-resolution sonography was used to detect recurrent thyroid carcinoma in 73 patients with papillary carcinoma, 16 with medullary carcinoma, 10 with follicular carcinoma, and one with small-cell carcinoma. Of the 36 patients with negative sonograms, 35 had no other evidence of recurrence, while one had surgical proof of recurrence. Of 25 patients with positive sonograms, confirmed with surgery or radioactive iodine (I131) scanning (sonographic sensitivity 96%, specificity 83%), palpation was negative in 17 (palpation sensitivity 32%, specificity 100%). Thirty-two patient with positive sonographic findings had no objective clinical proof of recurrence. There were seven false-positive studies. This study suggests that sonography may be the method of choice for earliest detection and localization of recurrent carcinoma of the thyroid.

Focal periportal sparing in hepatic fatty infiltration: a cause of hepatic pseudomass on US

An unusual pattern of hepatic fatty infiltration was detected sonographically in 31 patients over a 1.5-year period. At appropriate gain settings and time gain compensation, the liver parenchyma demonstrated diffuse increased echogenicity except for a solitary hypoechoic area with relatively distinct margins, usually located in the medial segment of the left hepatic lobe. This hypoechoic periportal focus varied in size between 1.5 and 5 cm and was typically ovoid, but was occasionally spherical or irregular in shape. Eight patients with such foci underwent percutaneous needle biopsy because of concern that there was a space-occupying mass. Microscopic examination of specimens from the hypoechoic periportal region revealed normal hepatic parenchymal cells, while tissue samples from the surrounding liver had high fat levels. In the remaining 23 patients, correlative radiologic studies supported the diagnosis of fatty liver and excluded a central-mass lesion. A localized area of normal hepatic tissue should be considered among the possible diagnoses when a circumscribed hypoechoic periportal area is demonstrated within a fatty liver.

Percutaneous drainage of subphrenic abscess: a review of 62 patients

Sixty-two patients who presented with subphrenic abscesses had the abscesses drained percutaneously. Diagnosis of a subphrenic collection was usually made with sonography. Initial percutaneous drainage was accomplished with a combination of sonography and fluoroscopic guidance. More recently (in the last 31 cases) most drainages were done with sonographic guidance alone. Successful catheter drainage was achieved in 85% with a complication rate of 4.8%. Failure of catheter drainage (defined as any patient who was not cured by percutaneous drainage alone) occurred in patients with multiple collections or in whom the primary cause of the abscess necessitated surgery, for example, perforated ulcer, acute cholecystitis. Considerations for successful drainage include understanding the anatomy of the subphrenic space, recognizing the importance of a correct access route (avoidance of the pleura and lung), and the long time necessary for adequate drainage (longer than 10 days in 60%). An angled subcostal approach to the subphrenic space was used in 56 (90%) of 62 cases. No complications occurred in this group. The one pneumothorax that occurred in the remaining six cases was a direct result of using an intercostal approach through the parietal pleura into a subphrenic collection. We conclude that percutaneous drainage is a safe and effective method of treatment of subphrenic abscesses.

MR-guided aspiration biopsy: needle design and clinical trials

Nonferrous needles of pure brass, titanium, or copper, and ferrous needles of different alloys of stainless steel were analyzed for the size, area, and distribution of the image artifact created when the needles were placed in a 0.6-T magnet. Results demonstrated that a stainless steel prototype needle (type 316) would be visible on magnetic resonance images and would provide an artifact similar to that seen in computed tomographic-guided biopsies. Further testing of this prototype included assessment of the effect on the artifact when changes were made in annealing properties, gauge, length, needle-tip geometry, pulse sequence, and orientation relative to the magnetic field. To date, three human liver biopsies have been successfully and safely performed using a stainless steel type 316 needle.

Microbubbles as a contrast agent for neurosonography and ultrasound-guided catheter manipulation: in vitro studies

Tissue-equivalent ultrasound phantoms, including models of the ventricular system and cyst phantoms, may be useful for developing expertise in both biopsy procedures and shunt catheter placement that use ultrasound guidance. These phantoms have been constructed (1) to assess the ability to position biopsy needles and manipulate shunt catheters with conventional angiographic guidewires and (2) to evaluate the usefulness of microbubbles as an ultrasound contrast agent. Optimal catheter and needle position and catheter patency are demonstrated with microbubbles generated by hand injection of small volumes of saline, a safe ultrasound contrast agent that, to our knowledge, has not been previously exploited in neurosonography. Microbubbles can define biopsy needle location without direct imaging of the biopsy needle; they can also define the extent of communication or separation of fluid-filled or loculated spaces.

Staging rectal cancer by MR and CT

Sixteen patients with known rectal cancer were evaluated and staged with CT and MR, and at surgery. Detailed evaluation of the pathologic specimens was performed and correlated with CT and MR to determine the accuracy of staging. Most of the cases were advanced stages, and both CT and MR were equally effective in staging. Prone positioning using an air-distension technique was equally important for CT and MR examinations. Because of a positive contrast material (iodine), adequate CT examinations could be performed without prior bowel preparation; however, bowel cleansing was necessary for MR examinations. Both techniques could identify the primary tumor and invasion into perirectal fat and local organs. Neither CT nor MR were able to assess the extent of bowel-wall infiltration or tumor spread to normal size perirectal lymph nodes.

Preoperative evaluation of abdominal aortic aneurysms by computed tomography

A prospective, preoperative study was conducted of 50 electively repaired abdominal aortic aneurysms comparing the CT and angiographic findings with those described at surgery. CT demonstrated all 50 aneurysms and correctly identified their proximal extent in relation to the takeoff of the renal arteries in 47 patients (94%), while angiography detected 48 aneurysms (96%) and their correct relation to the renal arteries in all (100%). CT correctly identified 40 (98%) of 41 patients with two renal arteries, but only two (29%) of seven with three and none of two patients with four arteries. Common iliac artery involvement or lack thereof was accurately predicted in 42 (84%) of the 50 patients and internal iliac artery aneurysms found in one (33%) of three patients. It was concluded that CT is not sufficiently accurate for documenting location and patency of the renal arteries to allow its routine substitution for angiography in patients undergoing preoperative assessment of abdominal aortic aneurysms.

Pancreatic necrosis: CT manifestations

Pancreatic necrosis is a potential sequela of acute pancreatitis, which pathologically represents a collection of devitalized tissue. Appropriate therapeutic planning requires definition of this irreversibly damaged gland, the presence of which is not consistently diagnosed on the basis of clinical and laboratory data. Over an 18-month period, 22 patients with pancreatic necrosis were studied by one or more computed tomographic (CT) examinations. Retrospective analysis showed the findings to vary with the developmental stage of the necrotizing process. During the acute phase, there was considerable morphologic overlap of necrosis and pancreatic phlegmon. Typical findings were seen in the subacute and chronic stages and included diffuse enlargement of the gland with largely decreased central density. A thick, smooth surrounding rim produced a characteristic saclike configuration. CT-guided aspiration for culture material was performed in four patients with suspected superinfection. Negative gram stain and culture results in two patients allowed surgery to be performed on a more elective basis.

Drainage of pelvic abscesses through the greater sciatic foramen

A computed tomographic (CT) guided transgluteal approach through the greater sciatic foramen was used to drain pelvic abscesses and fluid collections in 21 patients. Ideal catheter placement should traverse the lower portion of the greater sciatic foramen at the level of the sacrospinous ligament. This avoids the vascular and neural elements that are located slightly cephalad at the level of the piriformis muscle. Percutaneous drainage through this approach was successful in avoiding surgery in 17 patients (81%). Pain was the most common complication and was generally associated with a more cephalad approach, transgressing the piriformis and the sacral plexus. CT-guided percutaneous drainage of pelvic abscesses through the greater sciatic foramen should be used when the more standard transperitoneal approach is not possible.

Percutaneous drainage of postoperative abdominal and pelvic lymphoceles

Eleven patients with postoperative abdominal and pelvic lymphoceles underwent percutaneous diagnostic and therapeutic intervention with either needle aspiration or catheter drainage. Although initial sonographic or CT examinations accurately identified these collections, definitive diagnosis required fluid sampling and laboratory analysis for confirmation. Seven pelvic and two retroperitoneal lymphoceles demonstrated a gross appearance and composition different from two lymphatic collections in the upper peritoneum. Nine patients underwent catheter drainage; two were managed by needle aspiration alone. Duration of catheter drainage was 4-120 days, substantially longer than is customary for standard fluid collections. Nine of 11 patients were cured by percutaneous aspiration or drainage alone. Bacterial colonization developed in three persistently draining lymphoceles. However, no clinical sepsis or bacteremia occurred. In another patient with persistent high-volume lymphatic output, sclerotherapy with tetracycline instillation was successful in rapidly closing the lymphatic fistula. Percutaneous drainage is a safe, effective procedure for drainage of postoperative lymphoceles.

Surface coil MR imaging of abdominal viscera. Part III. The pancreas

Eight healthy volunteers and 11 patients with pancreatic abnormalities were studied using a conventional body coil and a prototype magnetic resonance (MR) surface coil. Final pathologic diagnoses included carcinoma of the head (six), body (one), and tail of the pancreas (two) and chronic pancreatitis (two). In surface coil images of the volunteers, the body and tail of the pancreas was visualized in all cases but one, and the pancreatic duct was seen in five of eight cases. In-plane spatial resolution of 0.9 X 0.9 mm and 5-mm section thickness was obtained. At the same time, pancreatic surface coil images had a twofold improvement in the signal-to-noise ratio (SNR) compared with body coil images. T1-weighted spin-echo images gave greater SNR, reduced motion artifacts, provided superior anatomic detail, and offered more diagnostic information than comparable T2-weighted images. Significant abnormalities detected only by surface coil imaging included a small tumor surrounded by reactive edema and periglandular tumor invasion. This study demonstrates that surface coil imaging of the pancreas not only is feasible but provides an improved method for examining the pancreas by MR.

Surface coil MR imaging of abdominal viscera. Part I. Theory, technique, and initial results

Prototype surface coil magnetic resonance (MR) images were obtained from phantoms and 42 subjects at 0.6 T to assess the feasibility of imaging relatively deep abdominal structures. Surface coil images demonstrated a two- to fourfold improvement in signal-to-noise ratio (SNR) when compared with whole-body coil images with the same resolution elements. This improvement in SNR allowed us to obtain images with thinner sections, higher in-plane resolution, or, alternatively, a decrease in image time. Compared with body images, surface coil images demonstrated greater anatomic detail and reduction in motion artifacts. Despite the limited field of view in very large patients, the use of surface coils improves the diagnostic capability of MR imaging of the abdomen.

Gallbladder bile in cholecystitis: in vitro MR evaluation

Fifty-three samples of gallbladder bile were obtained at the time of cholecystectomy from patients with the clinical diagnosis of acute or chronic cholecystitis. Five bile samples from patients with clinically normal gallbladders also were obtained. Proton magnetic resonance (MR) relaxation times, protein content, and water content were determined for the bile samples, and the data were grouped according to pathologic diagnosis, which disclosed 11 cases of acute cholecystitis, 41 cases of chronic cholecystitis, and six normal gallbladders. There was no significant difference in the mean T1 and T2 values between the groups with acute and chronic cholecystitis. Patients with chronic cholecystitis were found to have more concentrated bile than those with acute cholecystitis. Protein content varied widely within both groups of patients. We conclude that T1 and T2 relaxation times do not reliably differentiate acute from chronic cholecystitis.

Surface coil MR imaging of abdominal viscera. Part II. The adrenal glands

Magnetic resonance (MR) imaging of the adrenal glands with a prototype surface coil was compared with conventional body coil images in five healthy volunteers and 15 patients with adrenal disease. The spectrum of abnormalities included five nonfunctioning cortical adenomas, of which two were in hyperplastic glands, four adrenal metastases, three pheochromocytomas, a functioning adenoma, a myelolipoma, and a partially calcified, cystic adrenal mass. In both body and surface coil images, anatomic detail was superior on T1-weighted images compared with T2-weighted images obtained with identical imaging time because of decreased motion artifact and superior contrast. In the T1-weighted studies, high-resolution surface coil images showed a threefold improvement in signal-to-noise ratio (SNR) over body coil images, which was manifest by better intrinsic resolution of small adrenal lesions and clearer definition of the extrinsic relationships of large masses to nearby organs. In addition, inferior vena caval invasion by two right adrenal metastases was better demonstrated using the surface coil than body coil MR or computed tomography (CT). Limitations of surface coil imaging include restriction in the field of view to a single gland and additional time required for patient positioning. Since the sensitivity of surface coils diminishes with depth, gains in SNR were limited in large patients with deeper adrenal glands. Despite these limitations, dramatic improvements in SNR and anatomic resolution indicate that surface coil MR imaging will be competitive with CT for examining the adrenal glands.

Intrahepatic amebic abscesses: indications for and results of percutaneous catheter drainage

Medical therapy is standard for intrahepatic amebic abscess and generally is effective. However, we have encountered a group of patients in whom percutaneous aspiration and drainage was indicated due to uncertainty of diagnosis or clinical deterioration of the patient. Twenty such patients underwent percutaneous drainage with ultrasound or CT guidance, and each patient was cured (appropriate antibiotics were administered concomitantly). The specific indications for intervention were to differentiate pyogenic from amebic abscess, pain and imminent rupture, poor response to medical therapy, false-negative results of serologic tests, noncompliance with medical treatment, left lobe abscess, and pregnancy. Diagnosis of amebiasis from examination of the fluid was seldom possible, while findings from core biopsy of the wall of the abscess led to diagnosis in three cases. Recurrence necessitating redrainage occurred in three patients; in each, catheters were removed the same day drainage was performed. There were three minor complications. Differences from percutaneous management of pyogenic abscesses included more rapid removal of catheters (four days), more frequent use of US guidance, and more common use of the prone angled approach to avoid pleural contamination. Catheter drainage may be curative and may expedite care for problematic amebic liver abscesses in selected cases.

Inadvertent percutaneous catheter gastroenterostomy during abscess drainage: significance and management

Eleven cases of inadvertent catheter insertion into the small bowel or stomach during percutaneous abdominal abscess drainage are reviewed. Recognition of the intraluminal catheter position was made by contrast-enhanced fluoroscopy in all patients 1-6 days after catheter insertion. No evidence of leakage of intestinal contents into the peritoneal cavity was noted either clinically or radiologically. All cases occurred after drainage of a centrally located midabdominal collection, but the ultimate outcome was not compromised. In nine of 11 cases, catheter drainage alone was sufficient; two cases required additional surgical drainage. Considerations for management include a prolonged period of catheter drainage to allow evolution of a fibrous tract and gradual catheter withdrawal. These data confirm the growing experience with purposeful percutaneous gastrostomy that percutaneous catheterization of the gastrointestinal tract can occur without major sequelae.

Lesser sac abscesses and fluid collections: drainage by transhepatic approach

Twelve abscesses and fluid collections in the lesser peritoneal sac were drained percutaneously using an access route across the intervening liver. This rather unusual access was chosen when other approaches were contraindicated because of surrounding colon, stomach, or spleen. All collections were drained successfully, and no specific complications such as hemorrhage, bile leak, or liver abscess occurred. Placement of an abscess drainage catheter should be done through the peripheral portion of the liver if possible. The technique offers a new, safe approach to percutaneous drainage of hitherto inaccessible collections.

The bile ducts after a fatty meal: further sonographic observations

The sonographic appearance of the response of the common hepatic duct to physiologic stimulation by a fatty meal was assessed in 131 patients referred because of right upper quadrant symptoms or abnormal liver chemical studies. In the determination of the presence or absence of biliary obstruction, the sensitivity of the examination was 84%, the accuracy of a positive test was 84%, and the accuracy of a negative test was 93%. This test proved helpful in several circumstances: equivocal duct caliber (6-10 mm); abnormal caliber (6-14 mm) with normal laboratory values; normal caliber duct with abnormal laboratory values; persistent question of cholelithiasis or asymptomatic pancreatic duct dilatation. Measurements of bile duct caliber alone may be insufficient to ascertain the presence of bile duct obstruction and fatty meal stimulation significantly improves diagnostic accuracy.

Thyroid and parathyroid ultrasonography

The introduction of high-resolution real-time small-parts sonography has made imaging the superficial structures of the neck a practical procedure. This article reviews the normal anatomy of the neck as well as the benign and malignant diseases affecting the thyroid and parathyroid glands.

Percutaneous drainage of pyogenic liver abscesses

This report summarizes the results of percutaneous catheter drainage in 23 cases of primary or secondary pyogenic liver abscess. The overall success rate was 76%. Only three (60%) of five cases of secondary abscess (infected hematoma or infected tumor) were cured with catheter drainage, but 11 (91%) of the last 12 primary pyogenic abscesses were drained successfully. Six patients with abscesses of less than 4 cm in diameter required catheter drainage for less than 72 hr. Although six abscesses in the series appeared septated or multiloculated, only one required more than a single catheter for curative drainage. Diagnostic and technical considerations for successful drainage of hepatic abscesses are discussed. The differential diagnosis includes echinococcal disease and hepatic amebiasis. Therapeutically, specific measures should be taken to ensure proper catheter position to prevent contamination of the subphrenic, perihepatic, and pleural spaces. Percutaneous catheter drainage should be attempted as a first choice of treatment in all pyogenic hepatic abscesses.